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Salivary gland diseases Flashcards

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Introductory Sommelier Exam (CMS) flashcards
1
Q

How do you examine salivary glands? (2)

A
  • Visually - front, side and behind pt
  • Palpate
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2
Q

Which nervous pathway increases salivary flow?
Which decreases salivary flow?

A

Incr = Parasympathetic - cholinergic

Decr = Sympathetic - adrenergic

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3
Q

What CN innervates submandibular and sublingual gland? Incr salivary flow?

A

CN7 - facial nerve, chorda tympani

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4
Q

What CN innervates parotid gland? Incr salivary flow?

A

CN9, glossopharyngeal - lesser petrosal nerve

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5
Q

What CN innervates minor salivary glands? Incr salivary flow?

A

Both CN7 and CN9 - facial nerve and glossopharyngeal

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6
Q

How does the sympathetic, adrenergic pathway work? To decr salivary flow? (5)

A
  • Sympathetic outflow
  • Cervical ganglia
  • Plexus along artery walls
  • Branches to CNs
  • Innervates salivary glands
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7
Q

What does saliva contain?

A

99.4% water
0.6% minerals and proteins

  • Inorganic = sodium, potassium, chloride, bicarbonate, hydrogen, iodine, fluoride, calcium phosphate
  • Organic = urea, uric acid, AAs, glucose, lactate, fatty acids
  • Macromolecules = serum proteins, glycoproteins, peroxidases, amylase, lysozymes, IgA, IgG, IgM
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8
Q

What is the flow rate of saliva stimulated and non stimulated?

A

Stimulated = 4 - 5 ml/min
Non stimulated = 0.3 - 0.4 ml/min

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9
Q

How can you investigate salivary gland disease? (7)

A
  • Sialomertry
  • Oral rinse
  • Plain film radiography
  • Ultrasound
  • Bloods
  • MRI
  • Biopsy
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10
Q

How is Sialometry used?

A
  • Measure of saliva produced ml/min over 5-10mins
  • Crude technique, not used in practice
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11
Q

How is plain film radiography used?

A
  • Identifies radio opaque calculus
  • Needs 2 radiographs at 90 degrees to each other
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12
Q

How is Ultrasound used?

A
  • High freq sound waves can identify solid lesions incl. tumours / calculus / cysts
  • Not good for assessing salivary gland function
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13
Q

How is Sialography used?

A
  • Retrograde sialography examines ductal system using radio iodide
  • Shows structures, filling defects
  • Not good for investigating salivary tumours
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14
Q

How are bloods used?

A
  • Venous blood sample for xerostomia pt
  • Sjogren’s screen involves - FBC, liver function tests, urea, electrolytes, HbA1C (glucose test), serum immunoglobulins, hep C and HIV serology
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15
Q

What is Sjogren’s syndrome?

A
  • Autoimmune disease affecting exocrine glands
  • Effects moisture production
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16
Q

How is MRI used?

A
  • Magnetic Resonance Imaging
  • Demonstrates soft tissue detail
  • Ideal to see tumour extent and relation to normal anatomy
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17
Q

How are biopsies used?

A

Excisional for minor SGs - done IO
Incisional for major SGs - done IO / EO

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18
Q

What are symptoms of salivary gland diseases?

A
  • Swellings - localised / generalised / uni / bi-lateral / persistent / transient
  • Pain
  • Discharge from SG duct
  • Xerostomia / Sialorrhoea
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19
Q

What are the 11 salivary gland diseases need to know?

A
  • Obstructive
  • Xerostomia
  • Sialorrhoea
  • Sarcoidoisis / HIV related SG disease
  • Cancers
  • Benign neoplasias
  • Benign cysts
  • Acute / chronic sialadenitis
  • Frey’s syndrome
  • Developmental abnormalities
  • Primary / secondary Sjogren’s syndrome
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20
Q

What are main causes of obstructive SG disease?

A
  • Calculi
  • Strictures (narrowing of duct)
  • Infections
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21
Q

Define sialadenitis?
How is it categorised?

A

Inflammation of salivary gland
Infective
Obstructive

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22
Q

What else may cause obstructions of salivary glands?

A
  • Local swellings e.g. from cancers / lymph nodes
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23
Q

Describe salivary gland calculi

A
  • AKA Sialoliths
  • Most common cause of obstructive sialadenitis
  • Usually major salivary glands
  • Hard
  • Single / multiple
  • 80% involve submandibular gland
  • Can be asymptomatic
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24
Q

What causes strictures?

A

Trauma to the duct followed by fibrosis
Nearly all acquired

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25
Q

How common are strictures?

A

Less common than calculi / mucus plugs

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26
Q

How can localised strictures be treated?

A

Balloon dilation
But future re-stenosis may occur

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27
Q

What causes an acute obstruction and how is it described? How does it resolve?

A

Calculus / mucus plug
Recurrent, before eating, painful swelling of major SG
AKA mealtime syndrome
Resolves within 30 mins

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28
Q

How to manage calculi?

A
  • If asymptomatic - leave
  • If symptomatic and small can remove by incising to release stone
  • If symptomatic and large can retrieve endoscopically or remove whole gland
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29
Q

What are some of the associated risks when removing submandibular gland?

A
  • Damage to marginal mandibular nerve
  • Damage to lingual nerve
  • Damage to hypoglossal nerve
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30
Q

What are some of the associated risks removing parotid gland?

A
  • Damage to facial nerve, lading to unilateral facial weakness
  • Frey’s syndrome
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31
Q

What is the difference between hypo salivation and xerostomia?

A

Xerostomia = perception of dry mouth - subjective
Hyposalivation = reduced saliva production - objective

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32
Q

What can cause xerostomia? (9)

A
  • Medx
  • Diabetes
  • Anxiety
  • Mouth breathing
  • Dehydration
  • Irradiation to salivary glands
  • Acute infections
  • Recreational drug use
  • Sjogren’s syndrome
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33
Q

Which mechanisms cause drugs to suppress saliva production?

A

Central effects to brain
Anti-muscarinic effects
Sympathomimtrics (stimulate sympathetic nerves)

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34
Q

Name some prescribed drug groups which cause xerostomia

A
  • Tricyclic depressants
  • MAOIs
  • Antihistamines
  • Diuretics
  • Antipsychotics
  • Antiparkinsonian
35
Q

GDP level how can you manage xerostomia (11)

A

Smoking cessation
Alcohol cessation
Advise increase H20 intake
Avoid caffeinated drinks
Sugar free gum
Dietary advice to avoid cariogenic foods
F- intake through toothpaste / mouthwash / FVA
Increase freq of dental check ups
Discourage mouth breathers
Treat oral candidoses
Prescribe saliva substitute

36
Q

Why aren’t saliva substitutes / oral lubricants suitable for all pts? (3 examples)

A
  • Glandosane = acidic can cause erosion, so only suited to edentulous pts
  • BioXtra = made of cow’s milk, pt dietary preferences (unsuitable for vegans or lactose intolerant)
  • Saliva Orthana = made of porcine proteins, unsuitable for Muslim and Jewish pt
37
Q

What is Sialorrhoea and what is it also known as?

A
  • Ptyalism
  • Hypersalivation

Excessive production of saliva

38
Q

What can cause Sialorrhoea?

A

Parkinson’s
Cerebral Palsy
Acute viral infection
Rabies
Pregnancy
Teething
New dentures / orthodontist appliance
Pancreatitis
Mercury / Copper / Arsenic poisoning
Side effects of drugs

39
Q

How can Sialorrhoea be managed? (3)

A

Anti-muscarinics
Botox
Surigcally excising the gland

40
Q

How does Botox manage Sialorrhoea?

A

Injected into the salivary gland
Reduce ACh release
Inhibiting salivation

41
Q

What are the side effects of anti-muscarinics?

A

Can be worse than hypersalivation itself
- Urinary retention
- Constipation
- Overheating due to inhibited sweating

42
Q

What is sarcoidosis / HIV related salivary gland disease?

A

Chronic, multi-system, non-caseating granulomatous inflammatory disease of unknown cause

43
Q

What is sarcoidosis characterised by?

A

Enlarged lymph nodes across many parts of the body

44
Q

What can sarcoidosis / HIV related salivary gland disease cause?

A

SG swelling
Bilateral of parotids
Xerostomia

45
Q

What does HIV SG disease involve?

A
  • Uni/bilateral parotid gland swelling
  • Can cause cystic changes in SGs
46
Q

What is graft versus host disease a consequence of? How does it happen?

A

Transplants e.g. bone marrow transplant
Lymphocytes from the donor recognise recipient cells are foreign - so graft attacks the host

47
Q

What can be commonly seen in GvHD?

A

Xerostomia
Oral lichenoid lesions
Generalised mucosal inflammation
Candidoses
Oral hairy leukoplakia

48
Q

What are the 2 categories of SG cancers? Give examples

A

Benign neoplasms - pleomorphic adenomas, Warthin’s tumour
Malignant neoplasms - lymphoid, mucoepidermoid (common in parotid), adenoid cystic carcinomas (common in submandibular gland)

49
Q

Radiotherapy may be used for primary / secondary malignancies - which cells are most susceptible?

A

Serous cells > mucus cells

50
Q

What is glandular tissue replaced by following irradiation?

A

Reparative fibrosis

51
Q

What happens to saliva following radiotherapy?

A

Saliva production decreases and becomes thick with altered biochemistry and properties

52
Q

What are most benign neoplasias and which SG are they mostly found in?

A

Pleomorphic adenoma - 80%
Parotid gland

53
Q

Describe pleomorphic adenoma

A

Poorly encapsulated
Slowly enlarge over many years
Rarely become malignant

54
Q

How common are Warthin’s tumours? Describe and how are they managed?

A

Less common than PAs
Well encapsulated compared to PAs so surgical excision easier

55
Q

What is a mucocele an example of?

A

Benign cyst of minor SG
(Dilatation and accumulation of mucus)

56
Q

What is the main pt complaint with benign cysts?

A

Annoying and unaesthetic
Present as recurrent / persistent swellings in lower lip / buccal mucosa

57
Q

What does a mucocele in the upper lip suggest?

A

SG neoplasia - advise excision biopsy

58
Q

What is a ranula?

A

Sialocyst in FoM from sublingual SG
Type of mucocele
Unilateral
Raises tongue
(Frog like appearance)

59
Q

How is a ranula managed?

A

Marsupialisation - surgically cutting slit into cyst and suturing edges
Excision - rare

60
Q

What is Sialadentiis and what’s its origin?

A

Inflammation of SGs - acute or chronic
Viral origin - Mumps, CMV, HIV
Bacterial origin - Streptococcal or staphylococcus infection

61
Q

Which SG is acute sialadentis mostly seen?

A

Parotid

62
Q

Which SG is chronic sialadentis mostly seen?

A

Submandibular

63
Q

Signs of acute bacterial sialadentis

A
  • Parotid
  • Systemically unwell
  • Signs of acute inflammation
  • Pus drains into mouth
  • Foul taste
  • Erythema, heat and swelling EO (anterior to ears)
64
Q

How is acute bacterial sialadentis managed?

A
  • Acute symptoms need to be managed
  • ABX
  • Hydration and antipyretics
  • OHI to reduce reinfection risk
65
Q

Why is it more likely to get recurrent / chronic sialadentis after 1st exposure?

A

Fibrosis from initial inflammation

66
Q

Signs of chronic bacterial sialadentis

A
  • Submandibular gland
  • Evolves of period of months
  • Inflammation gets progressively more fibroses
  • Strictures / calculi
  • Sjogren’s syndrome
  • Intermittent pain, general aching / tenderness
  • Occasional pus secreted
67
Q

How is chronic sialadentis managed?

A

Surgical removal of gland

68
Q

What is Frey’s syndrome?

A

Neurological disorder
Damage to / near parotid glands
Damage to autonomic nerves supplying skin sweat glands and SGs

69
Q

Signs of Frey’s syndrome

A
  • Facial sweating
  • Facial flushing
70
Q

Management for Frey’s syndrome

A

Botox injections

71
Q

What kind of SG developmental abnormalities can occur?

A

Atresia = total absence of SGs
Hypoplasia = shrunken appearance of SGs

72
Q

Are there are symptoms from SGs with developmental abnormalities?

A

Asymptomatic usually
Other glands make up for reduced production from shrunken / missing SG

73
Q

What usually goes with primary / secondary Sjogren’s syndrome?

A

Systemic autioimmune condition
E.g. Rheumatoid arthritis RA
Systemic lupus erythematous SLE

74
Q

What does Sjogren’s syndrome affect?

A

Internal exocrine glands in pancreas, bowel, kidneys

75
Q

Who is affected by SS?

A

Females
2%
15% of RA pts have secondary SS
30% of SLE pts have secondary SS

76
Q

What can trigger SS?

A

Genetic predisposition
Herpes virus
Hep C

77
Q

Systemic signs of Sjogren’s syndrome

A
  • General fatigue - severe and debilitating
  • Inflammatory vascular disease
  • Raynaud’s syndrome - no blow flow to areas of body (causes it to appear white then blue)
  • Thyroiditis
  • Anaemia
78
Q

What are some subjective symptoms of xerostomia in pts with SS?

A
  • Nutritional deficiences
  • Difficulty swallowing / chewing
  • Sensitivity to spice
  • Salty bitter metallic taste
  • Burning mucosa
  • Lack of taste
  • SG swellings / pain
  • Cough
  • Altered saliva quality
  • Difficulty speaking, vocal disturbances
  • Lack of denture retention
79
Q

What are some objective signs of SS related to oral cavity?

A
  • Oral mucosa = dry, wrinkled, ulcerated, frothy saliva, lack of pooling of saliva in FoM
  • Tongue = dry, red, loss of papilla
  • Teeth = more caries, failed / fractured restorations
  • SGs = firm on palpation
80
Q

How to differentiate between primary and secondary SS?

A
  • Primary = dry mouth + eyes
  • Secondary = dry mouth + eyes + connective tissue disease
81
Q

What is Sicca syndrome?

A
  • Pts with dry mouth + eyes
  • But do not have SS
  • No other explanation for symptoms
82
Q

How to manage Sjogren’s syndrome

A

Palliative measures
- Increase lubrication
- Maintain OH
- Immunomodulating agents
- Pilocarpine - primary SS but side effects

83
Q

What is Sialosis?

A
  • Painless enlargement of major SGs
  • Bilateral and symmetrical
  • Soft to palpate
  • No xerostomia
  • No fever
  • No trismus
  • Uncommon
84
Q

What is sialosis associated with?

A

Alcoholism
Pregnancy
Diabetes
Anorexia
Bulimia

CMS (10 decks)

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